Palliative Care: Back to Basics
Dr Shirley H. Bush
Assistant Professor, Division of Palliative Care,
Department of Medicine
March 18, 2015
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[Back to Basics– Palliative Care – Dr. Shirley Bush]
Luke Fildes: The Doctor 1891
Oil on canvas, © Tate (tate.org.uk)
Overview of Session
• Knowledge Quiz
• In-class discussion of answers
• Palliative Care overview
– Starting opioids
– Management of nausea and vomiting
• End of life (EOL) care
– For MCC objectives “The Dying Patient”
• Resources on One45
– Guidelines for Opioids: Opioid Equivalency tables
• Don’t forget: The Pallium Palliative Pocketbook from Integration
Unit
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Pallium Palliative e-Book
• https://itunes.apple.com/ca/book/palliumpalliative-e-book/id901889273?mt=11
• http://www.amazon.ca/Pallium-PalliativeBook-Jos%C3%A9-Pereiraebook/dp/B00LH2D5WK
MCC Objectives – The Dying Patient
• http://apps.mcc.ca/Objectives_Online/objectives.pl?lang=englis
h&role=expert&id=25
• Key Objectives:
• Given a dying patient, the candidate will formulate an
appropriate palliative care plan that ensures optimal control of
pain and other symptoms, maintenance of human dignity, and
recognize the important role of family and social support.
[Back to Basics– Palliative Care – Dr. Shirley Bush]
MCC Objectives – The Dying Patient
• Enabling Objectives:
• Given a dying patient, the candidate will construct an effective
management plan, including:
a) discussion at the appropriate time with the patient as to his
wishes for care (e.g., resuscitation)
b) determining whether an advanced directive or substitute
decision-maker exists, if the patient is unable to express his
wishes
c) the use of pharmacotherapy (e.g., analgesia) for symptom
control, recognizing appropriate indications, side effects, and
complications
[Back to Basics– Palliative Care – Dr. Shirley Bush]
MCC Objectives – The Dying Patient
• Enabling Objectives CONTD:
• Given a dying patient, the candidate will construct an effective
management plan, including:
d) ensuring culturally sensitive emotional, physical, and spiritual
support to the patient and family, as appropriate
e) appropriate involvement of the healthcare team
f) referral to other health care professionals, as needed
[Back to Basics– Palliative Care – Dr. Shirley Bush]
MCC Objectives – Miscellaneous
• Vomiting and/or nausea:
• http://apps.mcc.ca/Objectives_Online/objectives.pl?lang=englis
h&role=expert&id=116
• Delirium: (Dr. Barbara Power: March 30, 2015/ Delirium SLM,
Palliative Care week of Integration Unit)
• http://apps.mcc.ca/Objectives_Online/objectives.pl?lang=englis
h&role=expert&id=58-2
• Truth Telling: (Integration Unit: Communication)
• http://apps.mcc.ca/Objectives_Online/objectives.pl?lang=englis
h&role=expert&id=121-2
[Back to Basics– Palliative Care – Dr. Shirley Bush]
B2B Session Objectives - I
• At the end of this session, students will be able to:
• Describe models of hospice palliative care and the principles on
which these are based.
• Discuss interprofessional collaboration in palliative and end-oflife care as a fundamental concept.
• Identify “total pain” incorporating the roles that psychological,
social, emotional and spiritual concerns, along with physical
symptoms, play in producing the pain experience.
• Identify the components of a holistic, interprofessional (IP)
assessment and plan of care for a terminally ill patient.
[Back to Basics– Palliative Care – Dr. Shirley Bush]
B2B Session Objectives - II
• Complete a ‘worked example’ for prescribing opioids in an
opioid naïve patient, and for opioid rotation.
• Outline the management of nausea and vomiting in advanced
cancer patients.
•
•
•
•
Describe 3 illness trajectories.
Identify signs of approaching death.
Describe common signs of the natural dying process.
Describe preparing the patient, family and caregivers, when
death approaches.
• Describe the pharmacological and non-pharmacological
management of patients at the end of life.
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Palliative Care Knowledge Quiz
• Test your own knowledge:
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 1
• Mrs. X is taking Long-Acting Morphine tablets 30 mg by
mouth every 12 hours for her pain, which has been well
controlled.
• She is now dying, and unable to take anything by mouth.
• The appropriate change in medication should be:
–
–
–
–
(a) 10 mg subQ q4h
(b) 5 mg subQ q4h
(c) 5-10 mg subQ q4h prn only
(d) crush the tablets, dissolve them in water, and administer same
medications buccally
– (e) 30 mg subQ q12 hours
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 2
• The dose conversion ratio of morphine to oxycodone in the
setting of palliative care is:
(a) 10 mg po of morphine = approximately 5-7.5 mg po of oxycodone
(b) 10 mg po of morphine = approximately 15 mg po of oxycodone
(c) 10 mg po of morphine = approximately 20 mg po of oxycodone
(d) 10 mg po of morphine = approximately 10 mg po of oxycodone
(e) 10 mg po of morphine = approximately 1 mg po of oxycodone
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 3
• A 55-year-old, 60-kg cancer patient with severe pain (8/10)
related to metastatic bone disease is in need of a strong
opioid. You decide to initiate him on a morphine regimen. He
has not previously been on a strong opioid and has normal
renal function. What starting dose would you use?
(a) Morphine (long acting formulation) 30 mg orally twice a day and
morphine (short-acting formulation) 5 mg orally every hour as needed (prn)
for breakthrough pain.
(b) Morphine (short-acting) 5-20 mg orally every 4 hours and morphine 5 mg
orally every hour as needed (prn) for breakthrough pain.
(c) Morphine (short-acting) 5 mg orally every 4 hours and 5 mg orally every
hour as needed (prn) for breakthrough pain
(d) Morphine (short-acting) 5 mg orally every hour as needed (prn) for pain.
(e) Morphine (short-acting) 5mg orally four times a day and 5mg orally as
needed (prn) for breakthrough pain.
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 4
• Which one of the following opioids is not recommended for
chronic pain management in palliative patients?
(a) Meperidine (Demerol)
(b) Codeine
(c) Methadone
(d) Oxycodone
(e) Fentanyl
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 5
• A 67 year-old man with advanced lung cancer and bone metastases is
taking slow release morphine 90 mg orally q12h. In the last two days he
has complained of increased generalized pain and his family have noticed
that he has become agitated, developed generalized myoclonus (muscles
twitching) and has started “picking at the air”.
• Which one of the following is the most appropriate change to make to his
opioid regimen?
(a) Switch his morphine to short acting hydromorphone at a dose of 8 mg orally q4h
(b) Switch his morphine to short acting hydromorphone at a dose of 4 mg orally q4h
(c) Increase the morphine dose to 120mg orally twice a day.
(d) Switch his opioid to transdermal fentanyl at a dose of 25 micrograms/hr every 3
days.
(e) Continue the morphine at the current dose and add baclofen to control the muscle
twitches.
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 6
• A 48 year-old man with advanced cancer presents with
delirium. He has cognitive impairment, mild agitation and
disturbing visual hallucinations. While searching for the
underlying causes, which one of the following treatments
would you initiate to control his delirium-related problems?
(a) Haloperidol 1mg orally q8hrs and haloperidol 1mg every hour if needed.
(b) Diazepam 5 mg to 10 mg orally twice a day and 5mg every hour if needed.
(c) Lorazepam 2mg orally or sublingually three times a day and 1mg every
hour if needed.
(d) Methotrimeprazine 12.5mg orally q12hrs and 12.5mg every hour if
needed.
(e) Midazolam: a bolus dose of 2.5mg subcutaneously followed by a
continuous infusion of 1mg to 4mg/hour titrated to control his agitation.
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 7
• Joe D. is a 73 year old man who was prescribed an opioid for
severe pain, due to metastatic prostate cancer, 2 days ago.
The medication has made him feel very nauseated. The most
appropriate first-line antiemetic which has its main effect on
the chemoreceptor trigger zone is:
(a) Dimenhydrinate (Gravol)
(b) Metoclopramide (Maxeran)
(c) Ondansetron (Zofran)
(d) Cannibinoid derivative (Marinol or Cesamet)
(e) Prochlorprazine (Stemetil)
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 8
• The presence of dyspnea in a terminally ill patient is best
determined by:
(a) A patient expressing that he is short of breath, without any other
objective measures.
(b) A patient expressing that he is short of breath, PLUS the use of accessory
breathing muscles.
(c) A patient expressing that he is short of breath, PLUS tachypnea
(d) A patient expressing that he is short of breath, PLUS hypoxia or
hypercarbia
(e) The presence of the use of accessory breathing muscles and tachypnea.
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 9
• A 68 year old man with progressive amyotrophic lateral
sclerosis (ALS) presents with increasing weakness and
shortness of breath, even at rest. He has no symptoms or
signs to suggest a pneumonia. Which one of the following
would be the most appropriate first-line symptomatic
management of his dyspnea at this time?
(a) Morphine 5mg nebulized (via an airway mask) every 4 hrs and every hour
as needed (prn).
(b) Morphine 5mg orally every 4 hrs and 5mg orally every hour as needed for
dyspnea.
(c) Lorazepam 1mg orally or sublingually three times a day.
(d) Non-invasive airway support with BIPAP.
(e) Tracheostomy with artificial ventilation.
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Question 10
• You have just written a prescription for hydromorphone
(Dilaudid) for a patient. You must also write a prescription for
a laxative. The best choice is:
(a) a stool softener, such as docusate sodium
(b) an enema, if needed
(c) a bowel stimulant e.g. senna derivatives or an osmotic agent
(d) a glycerine suppository
(e) methylnaltrexone
[Back to Basics– Palliative Care – Dr. Shirley Bush]
WHO Definition of Palliative Care - 2005
• “Palliative Care - an approach that improves QOL of
patients and their families facing the problem
associated with life-threatening illness, through the
prevention and relief of suffering by means of early
identification and impeccable Assessment and
Treatment of pain and other problems, physical,
psychosocial and spiritual”.
• http://www.who.int/cancer/palliative/definition/en/
• (Page not available in French)
[Back to Basics– Palliative Care – Dr. Shirley Bush]
• Effective palliative care requires a broad
multidisciplinary and interprofessional approach that
includes the family and makes use of available
community resources
• It can be successfully implemented even if resources
are limited
[Back to Basics– Palliative Care – Dr. Shirley Bush]
CHPCA Models of Palliative Care
(2002)
• Model
• Realistically
Bereavement
Care
Bereavement
Care
Therapy to cure or
control disease
Therapy to cure
or control
disease
Palliative
approach to care
Palliative
approach to care
Illness Trajectory
Illness trajectory
Dx
Dx
Death
[
Death
Aspects/Domains of Holistic Care
Physical, e.g.
Psychological, e.g.
-Disease management
-Pain & other symptoms
-Function
-Nutrition habits
-Physical activity
-Personality
-Psychological symptoms
-Emotions
-Control & dignity
-Coping responses
-Self image/ self esteem
-Loss & Grief
Social/Cultural, e.g.
Spiritual, e.g.
-Meaning & values
-Existential issues
-Beliefs
-Spirituality
-Rites & rituals
-Symbols & icons
-Loss & Grief
-Life transitions
-Religions
-Finances
-Relationships
-Personal routines
-Recreation
-Vocation
-Rituals
-Legal issues
-Family caregiver support
-Practical
]
Adapted from: “Domains of Issues Associated with Illness and Bereavement” in A Model to Guide Hospice Palliative
Care: Based on National Principles and Norms of Practice. CHPCA, March 2002, page 15.
Interprofessional (IP) Team Work
• Patients and families are experiencing a variety of needs representing the
different facets of their reality.
• In order to meet these needs which are often complex, the perspectives,
skills and resources of a variety of professionals are required.
– Physician collaborates with…….
•
•
•
•
•
•
•
•
•
•
Nurse (RN, RPN, APN, PCA – Personal Care Assistant)
Dietician/ Speech Language Pathologist (SLP)
Pharmacist
Physiotherapist/ Occupational therapist (PT/OT)
Psychologist
Recreation therapist
Social worker
Spiritual care professional/ Chaplain
Volunteer
Patient and family
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Medical Care of the Dying, 4th ed. Victoria Hospice Society; 2006
Conceptual Model of level of need within the population of
patients with a life limiting illness
A Guide to Palliative Care Service Development: a population based
approach . PCA 2005. Available at: http://www.palliativecare.org.au
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Episode of Care scenarios to meet Palliative Care needs
A Guide to Palliative Care Service Development: a population
based approach . Palliative Care Australia (PCA) 2005.
Available at: http://www.palliativecare.org.au
[Back to Basics– Palliative Care – Dr. Shirley Bush]
W.H.O. 3-step Analgesic Ladder
Opioid for mild
to moderate
pain
Non-opioid
e.g. paracetamol,
NSAIDs
+/– Adjuvant
STEP 1
[Back to Basics– Palliative Care – Dr. Shirley Bush]
+/– Non-opioid
+/– Adjuvant
Opioid for
moderate to
severe pain
+/– Non-opioid
+/– Adjuvant
STEP 3
STEP 2
Pain persisting or increasing
W.H.O. Analgesic “Ladder”
• Promoted 3 important concepts world-wide:
• By Mouth
• By the Clock
• By the Ladder
• N.B. not designed for use in isolation
• Is there still a role for Step 2?
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Initiating Opioids: “Worked example”
• Bernard is a 65 year old retired policeman who was diagnosed
with colon cancer 18 months ago.
• After surgery, his disease initially responded to chemotherapy,
but has now recurred with metastases to the liver and
peritoneum.
• He is experiencing increasing abdominal pain.
• He rates the pain as 6/10.
• He has been taking extra strength acetaminophen (1 to 2
tablets 3 to 4 times a day) with minimal effect.
• Q: Bernard has moderate to severe nociceptive pain:
• What opioid would you choose, and why? What starting dose?
[Back to Basics– Palliative Care – Dr. Shirley Bush]
“Worked example”: Answers
• Bernard is opioid naïve.
• Suggested starting doses:
– Morphine (IR) 5mg po q4hrs straight + 2.5 or 5mg po q1-2hr prn as
‘rescue’ dose/for breakthrough pain
– Hydromorphone (IR) 1mg po q4hrs straight + 0.5 or 1mg po q1-2hr
prn
• For ‘rescue’ dose:
– Generally, it is 10% of total daily dose.
– It should be titrated, so could be anything between 5-20% of total
daily dose if needed.
– If patient needs 3 or more ‘rescue’ doses/24 hours, the regular
opioid dose should be increased (assuming opioid-responsive
pain)
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Commencing Opioids
Common starting dose
Starting dose in frail, weak
patients or patients with
severe COPD
Morphine
5 – 10mg PO q4H straight
2.5 – 5mg PO q4H straight
Hydromorphone
1– 2mg PO q4H straight
0.5 – 1mg PO q4H straight
Oxycodone
2.5 – 5mg PO q4H straight 1 – 2.5mg PO q4H straight
(1) Discuss Opioid fears and misapprehension with patient: ‘Morphine Myths’
(2) Do also prescribe a ‘Rescue ‘ dose of IR (Immediate release) opioid for
‘breakthrough’ or ‘episodic’ pain: 10% of total daily dose
(3) Also see OPIOID EQUIVALENCY tables: on One45
[Back to Basics– Palliative Care – Dr. Shirley Bush]
When Commencing Opioids: Manage Potential
Side Effects
• Discuss potential side effects and strategies with patients
• Constipation: occurs in majority of patients and does not
resolve spontaneously
– Regular laxative e.g. senna, lactulose
• Nausea: in up to 2/3 of patients, but usually subsides within
3-7 days
– Antiemetic e.g. metoclopramide, haloperidol
• Somnolence/ Sedation: usually temporary for a few days
– Advise patient not to drive following opioid initiation, opioid
switch, significant dose increase for at least 5-7 days,
or if uncontrolled pain
• Respiratory depression (RR less than 8/min):
• Extremely low risk if appropriate starting dose and appropriate
titration
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Bernard: “Worked example” continued
• Q: How would you titrate the opioid dose up, if Bernard’s pain
remains poorly controlled?
• Method 1: Increase the dose by 20-30%
• Method 2:
– Add up the # of ‘rescue’ doses used in previous 24 hours
– Add these to the total dose of regularly scheduled doses over
last 24 hour period
– Now divide this total by 6 to get the new 4-hourly dose
• Q: Bernard still has pain despite Morphine 10mg po q4hr plus
4-5 PRN doses of 5mg/day: What morphine dose would you
prescribe now?
• Morphine 15mg po q4hrs straight
• Don’t forget to increase ‘rescue’ dose too
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Bernard: “Worked example” continued
• 2 weeks later, Bernard’s pain is under good control (2/10).
He is now on Morphine (IR) 20mg po q4hrs straight, and
taking only 1 -2 ‘rescue’ doses a day. He finds the q4hr
regimen inconvenient.
• Q: What dose of slow release morphine would you start?
• Slow release Morphine 60mg po q12hrs
• And continue IR Morphine for breakthrough pain
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Bernard: “Worked example” continued
• Bernard’s disease progresses. He is managing at home with his
wife, family, and community team (Family physician and home
care nursing). He now develops vomiting from a bowel
obstruction.
• Q: How will you control his pain now that the oral route is no
longer working?
• Change to subcutaneous route.
• Generally, the po: subcut conversion dose for both Morphine and
Hydromorphone is 2:1
• Morphine SR 60mg po q12hrs = Morphine 120mg po/24 hours
• = Morphine 60mg subcut/24hrs = 10mg subcut q4hr straight
• Add subcut option for breakthrough pain (Morphine 5mg subcut
q1hr prn)
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Opioid-Induced Neurotoxicity (OIN)
Therefore we
may give more
Agitation often
Interpreted as
increasing pain
Opioids
Dehydration
(decrease po.
Intake…)
leading to
progressive
renal failure
OIN – delirium,
agitation,
+/hyperalgesia
Accumulation
of
Opioid
metabolites
Alice: Opioid Rotation Question
• Alice: 73 y.o. metastatic breast cancer
• Lives with frail husband @home, regular CCAC and GP visits
• PPS (Palliative Performance Scale) 50%
• PPS 50% = mainly sit/lie, requires considerable assistance
• Increased pain++ Right hip
• Morphine dose increased from 60mg subcut/24h to 120mg
subcut/24h within the last 7 days….
– Alice is somnolent
– Her husband says she has been confused
– Mild myoclonus of both legs observed
• You, as her visiting MD, are concerned that she is opioid toxic.
• How would you rotate her to hydromorphone?
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Alice: Opioid Rotation Answer
• For opioid rotation Morphine (M) → Hydromorphone (HM)
• 10mg subcut M = 2mg subcut HM (i.e. 5:1)
– See Guidelines for Opioids: Opioid Equivalency tables on One 45
• So 120mg M subcut/24h = 120/5 = 24mg HM subcut/24h
• BUT: equianalgesic dose of the new opioid should be
reduced by 30-50% because of incomplete cross tolerance
• 30% of 24mg HM subcut/24h = 7.2mg
• Thus, suggested final dose = 24-7= 17mg HM subcut/24h
• Also:
–
–
–
–
Review other medications, especially other psychoactive drugs
Consider hydration
? Role for non-opioid co-analgesic/adjuvant
Imaging R hip: ? Role for palliative RADS
[Back to Basics– Palliative Care – Dr. Shirley Bush]
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Multi-factorial Causes of Nausea and Vomiting
in patients with advanced cancer
Gastric outlet obstruction /
intestinal obstruction
Severe
constipation
Autonomic failure /
delayed gastric
emptying
Gastroesophageal reflux
disease / gastritis / peptic ulcer
disease / gastric compression /
‘squashed stomach syndrome’/
gross ascites
Drugs
e.g. opioids,
antibiotics, digoxin
Psychological factors /
anxiety / anticipatory
(conditioned)
Metabolic disorders
e.g. hypercalcemia,
hyponatremia, liver
failure, renal failure
Nausea and
Vomiting
Oral / esophageal
infection or lesions,
esophagitis
Toxins
e.g. sepsis, urinary tract infection,
tumor produced peptides
Chemotherapy /
Radiotherapy
Vestibular stimulation
e.g. motion sickness, Menières,
labyrinthitis, base of skull disease
Raised intracranial pressure
e.g. brain tumor or metastasis,
leptomeningeal disease
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Common Causes of Nausea & Vomiting in Advanced Cancer
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Major Emetogenic Pathways
Pain, anxiety,ICP,
anticipatory (pre-CT)
e.g. lorazepam
dexamethasone
Shirley Bush 2014
Motion
e.g.
dimenhydrinate
(Gravol)
H1
_
Achm
+
+
CTZ
D2
5HT3
Drugs, biochemical disorders,
toxins via systemic circulation
e.g haloperidol, (metoclopramide)
(prochlorperazine action
at Vestibular input, CTZ
and Vomiting Centre)
+
Vestibular input
+
+
Higher cerebral
centres
Vomiting
Centre
H1 Achm 5HT3 5HT2
e.g.
dimenhydrinate
(Gravol)
+
VAGUS
Effector organs
Liver
Gut
D2 5HT3
5HT4 Ach
G.I. Distension,
obstruction, liver mets.
e.g. metoclopramide
domperidone
Methotrimeprazine (Nozinan)
• A more sedating phenothiazine than prochlorperazine
(Stemetil)
• Long T ½
• Used in palliative care as anti-emetic and for agitated
delirium
• (Like Stemetil) Broad receptor coverage
• D2, H1, Ach, 1 adrenoreceptors, 5HT2
• CTZ antagonist, Vomiting centre, Vestibular system and gut
• Also adjuvant analgesic effect
• NB: Many anti-emetics
– Extrapyramidal adverse effects
– QTc prolongation
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Anatomical Reflex Pathways


We have N & V as protective mechanisms
Sight, smell, taste:


To detect contaminated food stuffs
Receptors in upper gut detect toxins



E.g. Vagus from gut (Peripheral Dopamine D2
receptors)
Also gut Acetylcholine (Ach) receptors
And gut Serotonin (5HT3) receptors
5HT3 receptors

Via gut 5HT3 (serotonin) receptors



Serotonin located in enterochromaffin cells in gut
wall
Released and metabolised locally in response to
various insults, including radiotherapy with gut in
field and highly emetogenic chemotherapy
(N.B. also 5HT3 receptors in V.C. (and CTZ)
Major N & V Pathways - 1


VAGUS from gut (Peripheral Dopamine D2 receptors)
CTZ = Chemoreceptor Trigger Zone






Area Postrema in floor of 4th ventricle in medulla
Effectively NO blood brain barrier
Capillaries of AP – leaky fenestrated endothelium,
permitting direct chemical communication between blood
and subarachnoid CSF
So sensitive to CHEMICAL stimulation from blood/ CSF
Principal central receptors - Dopamine D2,
(also 5HT3)
(Vagal afferents from gut also project to CTZ)
Major N & V Pathways - 2

Impulses from CTZ to VC



Sensory information processed in tractus
solitarius and its nucleus
(and vomiting initiated by dorsal motor nucleus
of the vagus and nucleus ambiguus)
CTZ may also send outputs directly to VC
efferent components
Major N & V Pathways - 3

VC = Integrated Vomiting Centres




Neuroanatomical region
Adjacent co-ordinated sites in lateral reticular formation of
the medulla
Also receives afferents from GIT, thorax, vestibular system,
thalamus, higher brain stem and cerebral cortex
Consists of:
 Nucleus tractus solitarius
 Main efferent motor components of VC
 Dorsal motor nucleus of vagus & nucleus ambiguus
Major N & V Pathways - 4

Integration of emetogenic stimuli with
parasympathetic activity and Stimulation of these
motor efferent pathways from VC  vomiting

Principal receptors are:
Histamine H1
Muscarinic cholinergic Achm
Serotonin 5HT3
+ others, e.g. 5HT2




Major N & V Pathways - 5

Vestibular system (via Achm / H1 receptors)



Motion sickness, Meniere’s disease, labyrinthitis
Malignant infiltration of vestibular apparatus
 E.g. acoustic neuroma, 10 and 20 cerebral tumours,
base of skull disease
Drugs e.g. platinum, aspirin
Major N & V Pathways - 6

Via Cortical Centres




Effect of memories on sensitising the whole process
Anticipatory N & V pre chemotherapy
Raised ICP
 E.g. 10 and 20 CNS tumour
 E.g. meningitis (carcinomatous, chemical, infection)
Psychological factors, anxiety
N & V: Non-Pharmacological Management
• Assist patient to sit upright in bed, or out of bed, for
meals
• Encourage family to bring in foods that patient likes
and can tolerate
• Try easily digested foods (add sauces)
• Small attractive meals, little and often
• Refer to dietician to increase food choices
• Flat ginger ale
• At home, avoid smell of cooking food
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Non-Drug Management for N & V
• Acupuncture /
acupressure wrist bands
(Sea Bands™)
• Anxiety management
• Behavioural therapy with
systematic
desensitization –
anticipatory emesis with
chemotherapy
[Back to Basics– Palliative Care – Dr. Shirley Bush]
– P6 (Neiguan) acupuncture
point = midline of palmar
aspect of wrist, about 3cm
from palmar crease
– Acupuncture point
stimulation  acute CINV
– Acupressure may  acute
nausea
– Ezzo JM et al.
Acupuncture-point
stimulation for
chemotherapy-induced
nausea or vomiting;
Cochrane 2006
Illness Trajectories
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Murray SA , et al. BMJ 2008;336:958-9
3 Triggers for Palliative/ Supportive Care
• (1) The ‘Surprise’ Question:
– Would you be surprised if this patient were to die in the
next 6 - 12 months?
• (2) Choice/Need
• (3) Clinical indicators: Specific indicators of advanced disease
for each of the 3 main EOL patient groups
• Prognostic Indicator Guidance from the Gold Standards
Framework ™
• Available @
• www.goldstandardsframework.org.uk
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Prognosis: “Doctor: How long do I have to live?”
• How frequently is the
patient observed to
decline?
The Thinker, Auguste Rodin, 1902
– Every Month: estimated
prognosis of months
– Every Week: estimated
prognosis of weeks
– Every Day: estimated
prognosis of days
– Every Hour: estimated
prognosis of hours
BUT with caveat: in setting of advanced cancer, patient’s condition
can change very quickly (Another disclaimer: life expectancy can be longer)
[Back to Basics– Palliative Care – Dr. Shirley Bush]
See Chapter 4 in Pallium Palliative Pocketbook
Goals of Care
• Establish patient’s Goals of Care
• Assess the patient and/or family’s knowledge of the illness
and prognosis
• Assess priorities
– Comfort – Allow a Natural Death
– Life-prolongation
– Special events
• Communication: Is everyone on the same page?
– Role for Family Meeting
• Detailed documentation, including ‘level of care’, code status
[Back to Basics– Palliative Care – Dr. Shirley Bush]
See Chapter 3 in Pallium Palliative Pocketbook
The Normal Dying Process - The Last Days
•
•
•
•
•
•
•
Weaker: need assistance with all care
Bed-bound
Reduced oral intake - food/ fluids
Difficulty swallowing oral medications
Drowsy or reduced cognition and difficulty concentrating
More time asleep
Some symptoms may increase e.g. delirium, dyspnea
• “Withdraw” - say their goodbyes
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Signs that Death is Imminent: “days to hours”
• Explain these signs to the family and other caregivers:
• CNS: Refractory delirium (in up to 88% of patients @ EOL),
(N.B. exclude reversible causes e.g. urine retention, opioid toxicity),
Reduced consciousness
• RESP: Rate, pattern
– Altered breathing
• Cheyne-Stokes respiration
• Periods of apnea
• Agonal breathing
– Profuse upper airway secretions – “terminal respiratory
congestion” or “death rattle”
• CVS: Weak and rapid pulse, decreased capillary refill
• SKIN: Cold extremities, mottling of periphery (hands, feet, legs)
• GU/GI: Reduced output
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Terminal Respiratory Congestion: “Death Rattle”
•
•
•
•
Inability to clear secretions from oropharynx and trachea
Relaxation of pharynx
Noisy “rattling” respiration
Patients usually unconscious/ semi-conscious and too weak to
expectorate – likely not distressing to patient
– Explain to and reassure family
• Nursing care
–
–
–
–
Nurse semi-prone
Nurse side to side
Maintain scrupulous oral hygiene
Suction rarely required
• Light oral suctioning may be needed – avoid deep suctioning
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Terminal Respiratory Congestion Management contd.
• Discontinue parenteral fluids
• Anticholinergic drugs may be required….
– Reduce production of pharyngeal secretions
– ? Less effective on chest secretions compared with oral
secretions
– E.g. Glycopyrrolate 0.2 – 0.4 mg subcut. q2-4 hr PRN
– E.g. Hyoscine hydrobromide (Scopolamine™) 0.2 – 0.4 mg
subcut. q2-4 Hr PRN
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Still
Active Management of Symptoms
• Prepare patient and family (Difficulty with prognostication)
• Full nursing cares - for patient comfort and dignity
–
–
–
–
–
–
Eyes: Artificial tears, lacrilube eye ointment
Nose: Reassess nasal prongs, salinex gel
Oral hygiene: Regular mouth care, moisture spray, gels
GI: Suppository PRN
GU: Pads, Foley catheter PRN
Skin: Pressure area care (Including mattress)
• Ongoing review and relief of physical symptoms
–  delirium,  dyspnea @ EOL
• Psychosocial (settle affairs)/ spiritual and/or religious needs
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Preparing for Death
• Communication with family: explanation and support
• Clinical management
– Vitals – discontinue
– Investigations – discontinue
– Life-prolonging treatments
• Evaluate benefit, role in ongoing symptom management
• Stop non-essential medications/ ? Discontinue oxygen
– Comfort treatments – continue/ institute
• Appropriate dosing & schedule
– Parenteral route for medications (subcut. route generally) when
patient no longer able to swallow/ in anticipation of this
• Review role for Medically Assisted Hydration & Nutrition
• Deactivate Implantable Cardioverter Defibrillator (ICD)
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Review Venue of Care
• Knowledge of options available
• ? Hospital vs. Palliative Care unit vs. hospice vs. nursing
home/LTC vs. home
• Single room if possible
• If needed, liaise with Palliative Care Hospital Consult service
– Liaise with Family Physician – As Early as possible
– Community palliative care team (24 hr cover) - RPCT
– Referral to community nursing service (CCAC)
• Supply of drugs with medication orders, hospital bed and
other equipment, ?Foley catheter, ? Dressings, ??Oxygen
• Insert indwelling Subcut. butterfly needle
• Urgent ambulance home/ completed MOHLTC DNR order
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Planning for Crises
• Community: Supply of emergency drugs at home
– E.g. Subcut. opioid, neuroleptic, antiemetic, benzodiazepine,
anticholinergic (EOL)
• Risk of Hemorrhage
• E.g. Carotid hemorrhage in Head and Neck (H&N) cancer
• E.g. Massive GI bleed, massive hemoptysis
– Discuss with family and staff
– Green towels
– Catastrophic order/ Crisis pack
• Midazolam 5- 10mg subcut. (or I.M.), +/- Usual opioid rescue dose
and repeat q5 minutes PRN if needed
– Stay with patient (At home: advise family not to call 911 – DNR
order in place)
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Essential Medications at EOL ……
• Cessation or subcut. conversion of oral medications
– Consider continuous Subcut. infusion
• ? Opioid (e.g. for pain, dyspnea)
• +/- Antipsychotic for delirium
– E.g. Haloperidol, methotrimeprazine (Nozinan™)
• +/- Sedative agent for refractory delirium, refractory dyspnea
at the end of life
– E.g. Midazolam, lorazepam, methotrimeprazine (Nozinan™),
phenobarbital
• +/- Antiemetic
• +/- Anticholinergic for respiratory secretions
– E.g. Glycopyrrolate, hyoscine
• Review parenteral fluids/ oxygen
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Caring for Patients - and Families - at the End of Life
•
•
•
•
•
Address fears and concerns
Reassurance where appropriate
? Hearing and Touch last senses to go
Suggest notifying family/ friends, especially if overseas
Consider allied health support (social work, spiritual care,
psychology) if not already involved
• Ensure family members looking after selves (eating, drinking,
sleep)
• “Keeping vigil”: Give permission for family to leave room and
take breaks, or create a roster for family shifts
• Enquire if any cultural or religious/spiritual needs for end of
life care, and after death
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Orienting Ourselves for End of Life (EOL) Care
• Reflective Discussion Video – Orienting Ourselves for Hospice,
Palliative & EOL Care (5 minutes)
• From pallium.ca
• http://www.youtube.com/watch?v=sP4Fkjn3OwU
[Back to Basics– Palliative Care – Dr. Shirley Bush]
• Any Questions…..
• Please feel free to contact me:
• sbush@bruyere.org
[Back to Basics– Palliative Care – Dr. Shirley Bush]
Guerir quelquefois
Soulager souvent
Consoler toujours
To cure occasionally
To relieve often
To comfort always
Death in the sickroom, Edvard Munch, 1895
[Back to Basics– Palliative Care – Dr. Shirley Bush]